Form DPBH PHR150 O "Release of Protected Health Information Consent Form - Outpatient Services" - Nevada

What Is Form DPBH PHR150 O?

This is a legal form that was released by the Nevada Department of Health and Human Services - a government authority operating within Nevada. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2017;
  • The latest edition provided by the Nevada Department of Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DPBH PHR150 O by clicking the link below or browse more documents and templates provided by the Nevada Department of Health and Human Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form DPBH PHR150 O "Release of Protected Health Information Consent Form - Outpatient Services" - Nevada

Download PDF

Fill PDF online

Rate (4.3 / 5) 73 votes
Name: ________________________ Social Security #:_XXX-XX-_____________Birth date:______________________
INFORMATION TO BE RELEASED FROM:
Name/Agency (above): Northern Nevada Adult Mental Health Services – Opt Services
Phone #: (775) 688-2078
Address:
480 Galletti Way
Sparks, Nevada 89431
Fax #:
(775) 688-2036
INFORMATION TO BE RELEASED TO:
Name/Agency: ___________________________________________________ Phone #:____________________________
Address: ________________________________________________________ Fax #:______________________________
MUST BE INITIALED: ______Written Disclosure
______Verbal Disclosure
________ Electronic transfer / FAX
Email address:_________________________________ FAX # (if different from above):____________________________
PURPOSE OF RELEASE: _____ Personal _____ Legal _____Other: ___Continuity of Care___________________
DATE(s) OF SERVICE: FROM _________________________________ TO ____________________________________
INFORMATION TO BE RELEASED: (Individual MUST INITIAL each item of information to be released)
______ Psychiatric/Drug/ Alcohol Information
______HIV/AIDS Information
______Consultation Reports
_______History & Physical Exam
______Treatment Plans
______Diagnosis (psychiatrist)
_______Discharge Summary
______Psychiatric Evaluation
______Psychological Assessment
_______ Medication Records
________Progress Notes
______ Lab / EKG Results
______General Summary Letter Only
______Other (Specify):__________________________________________________________________________________________________________
INFORMATION FOR INFORMED CONSENT
The confidentiality of medical, psychiatric and substance abuse information is protected by State and Federal Statutes, Rules and Regulations including
Nevada Revised Statutes and Title 42 of the Code of Federal Regulations. These Statutes, Rules and Regulations require that the individual give informed
consent prior to the release of any health/hospital records or information, except as specifically provided for within the Statutes, Rules and Regulations. A
general authorization for the disclosure of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information
to criminally investigate or prosecute any alcohol or drug abuse patient.
Consent to release information will be considered valid only when it states: (1) who will release the information; (2) who will receive the information; (3) the
purpose for which the information will be used; (4) what specific information will be released; and (5) when the consent will expire. The consent must contain
the individual’s or authorized representative’s signature and the date of the signature. The authorized representative signing for the client must submit a copy
of the legal document(s) granting this authority.
This authorization for the Release of Medical Information waives any and all rights that the individual now has or in the future may have to bring any legal
action against the releasing person/facility for any damages caused directly or indirectly by the release of this information or other confidential information.
Upon request, the individual will be given a copy of the completed “Authorization for the Release of Protected Health Information.”
This authorization is effective immediately and is subject to revocation in writing at any time, except to the extent that action has already been taken in reliance
thereon. Otherwise, this authorization expires________ days from the date of signing (but no longer than 365 days) or upon case closure, whichever occurs
first.
A PHOTOCOPY, FACSIMILE OR ELECTRONIC SUBMISSION OF THIS FORM IS AS VALID AS THE ORIGINAL
Date: _______________________
Date: _______________________
__________________________________
_____________________________________________
Signature of Parent/Guardian/Representative)
Signature of Client
____________________________________________
_________________________________________________________
Relationship to Client
Signature of Witness
DIVISION OF PUBLIC AND BEHAVIORAL HEALTH
NAME: __________________________________
Northern Nevada Adult Mental Health Services
Outpatient Services
#:______________________________
Health Record
Release of Protected Health Information Consent Form
DPBH PHR 150 O
Page 1 of 2
Rev.8/2017
Copies cost $.60 per page
Name: ________________________ Social Security #:_XXX-XX-_____________Birth date:______________________
INFORMATION TO BE RELEASED FROM:
Name/Agency (above): Northern Nevada Adult Mental Health Services – Opt Services
Phone #: (775) 688-2078
Address:
480 Galletti Way
Sparks, Nevada 89431
Fax #:
(775) 688-2036
INFORMATION TO BE RELEASED TO:
Name/Agency: ___________________________________________________ Phone #:____________________________
Address: ________________________________________________________ Fax #:______________________________
MUST BE INITIALED: ______Written Disclosure
______Verbal Disclosure
________ Electronic transfer / FAX
Email address:_________________________________ FAX # (if different from above):____________________________
PURPOSE OF RELEASE: _____ Personal _____ Legal _____Other: ___Continuity of Care___________________
DATE(s) OF SERVICE: FROM _________________________________ TO ____________________________________
INFORMATION TO BE RELEASED: (Individual MUST INITIAL each item of information to be released)
______ Psychiatric/Drug/ Alcohol Information
______HIV/AIDS Information
______Consultation Reports
_______History & Physical Exam
______Treatment Plans
______Diagnosis (psychiatrist)
_______Discharge Summary
______Psychiatric Evaluation
______Psychological Assessment
_______ Medication Records
________Progress Notes
______ Lab / EKG Results
______General Summary Letter Only
______Other (Specify):__________________________________________________________________________________________________________
INFORMATION FOR INFORMED CONSENT
The confidentiality of medical, psychiatric and substance abuse information is protected by State and Federal Statutes, Rules and Regulations including
Nevada Revised Statutes and Title 42 of the Code of Federal Regulations. These Statutes, Rules and Regulations require that the individual give informed
consent prior to the release of any health/hospital records or information, except as specifically provided for within the Statutes, Rules and Regulations. A
general authorization for the disclosure of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information
to criminally investigate or prosecute any alcohol or drug abuse patient.
Consent to release information will be considered valid only when it states: (1) who will release the information; (2) who will receive the information; (3) the
purpose for which the information will be used; (4) what specific information will be released; and (5) when the consent will expire. The consent must contain
the individual’s or authorized representative’s signature and the date of the signature. The authorized representative signing for the client must submit a copy
of the legal document(s) granting this authority.
This authorization for the Release of Medical Information waives any and all rights that the individual now has or in the future may have to bring any legal
action against the releasing person/facility for any damages caused directly or indirectly by the release of this information or other confidential information.
Upon request, the individual will be given a copy of the completed “Authorization for the Release of Protected Health Information.”
This authorization is effective immediately and is subject to revocation in writing at any time, except to the extent that action has already been taken in reliance
thereon. Otherwise, this authorization expires________ days from the date of signing (but no longer than 365 days) or upon case closure, whichever occurs
first.
A PHOTOCOPY, FACSIMILE OR ELECTRONIC SUBMISSION OF THIS FORM IS AS VALID AS THE ORIGINAL
Date: _______________________
Date: _______________________
__________________________________
_____________________________________________
Signature of Parent/Guardian/Representative)
Signature of Client
____________________________________________
_________________________________________________________
Relationship to Client
Signature of Witness
DIVISION OF PUBLIC AND BEHAVIORAL HEALTH
NAME: __________________________________
Northern Nevada Adult Mental Health Services
Outpatient Services
#:______________________________
Health Record
Release of Protected Health Information Consent Form
DPBH PHR 150 O
Page 1 of 2
Rev.8/2017
Copies cost $.60 per page
REVOCATION:
I hereby revoke the authorization given on the reverse side of this page
Date/Time______
Signature of Patient
Date/Time_____
Signature of Guardian/Representative (Legal documents required)
Date/Time_____
Signature of Witness
The following information was released to: (list by PHR # and date i.e., PHR 103 2/99, 3/01)
___________________
___________________
_________________
________________
___________________
___________________
_________________
________________
___________________
___________________
_________________
________________
Was released to: ______________________________________________________________________
____________________________________________________________________________________
Via
mail
verbal
fax
e-mail
Picked up by: ____________________________ Date: ________Time____
(signature required)
Released by: ______________________________________________ Date: _________Time________
The following information was released to: (list by PHR # and date i.e., PHR 103 2/99, 3/01)
___________________
___________________
_________________
________________
___________________
___________________
_________________
________________
___________________
___________________
_________________
________________
Was released to: ______________________________________________________________________
____________________________________________________________________________________
Via
mail
verbal
fax
e-mail
Picked up by: ____________________________ Date: ________Time____
(signature required)
Released by: ______________________________________________ Date: _________Time________
The following information was released to: (list by PHR # and date i.e., PHR 103 2/99, 3/01)
___________________
___________________
_________________
________________
___________________
___________________
_________________
________________
___________________
___________________
_________________
________________
Was released to: ______________________________________________________________________
____________________________________________________________________________________
Via
mail
verbal
fax
e-mail
Picked up by: ____________________________ Date: ________Time____
(signature required)
Released by: ______________________________________________ Date: _________Time________
Authorization for Disclosure of Health Information
DPBH PHR 150 O
Page 2 of 2
8/17
Page of 2